Birth control options for a 41 year old?October 10, 2011 7:15 AMSubscribe

What are good birth control options for a 41-year-old woman who hasn't entirely given up the chance of having children?

I was on birth control pills into my early- to mid-30s and didn't have any problems, but I've used condoms with the last two boyfriends, both of whom were fine with them. My new boyfriend, though, whom I like very much, doesn't do well with condoms. (He's bigger than average. He doesn't get off with them very often. And they sometimes break.) We're both STD free and historically monogamous people. I can imagine being with this man for a long, long time.

I'm 41. I weigh about 200 pounds and have lost about 50 pounds in the last 1.5 years. I've never been a smoker. I run a lot and feel quite strong and fit, and my last physical was excellent. But high blood pressure runs in both sides of my family (as do heart disease and diabetes), even though my blood pressure currently is fine. I also really don't want to take anything that will make me gain weight, and my body seems pretty happy to hold onto--or put on--weight. I also haven't entirely given up the thought of having a biological child and would have to act soon-ish, something the boyfriend is interested in, too, but we don't yet know each well enough to act now. My understanding is that an IUD or the NuvaRing is for someone who doesn't want to be pregnant for years, and I don't have that kind of time.

You could try a diaphragm or cap. And whilst a Nuvaring is supposed to be good for long term use, since you have to change them every 4 weeks it might be a good short-term option too.posted by plonkee at 7:19 AM on October 10, 2011

The IUD is meant for longer-term use, but it can be removed at any time. Anecdata: from the experiences of some people I know, the hormones must leave your body quicker than with oral contraceptives, because they've gotten pregnant pretty quickly after removal.

NuvaRing is pretty much the same way. Just don't put a new one in.posted by Madamina at 7:22 AM on October 10, 2011 [1 favorite]

Just asking the obvious question first: have you tried the "Magnum" size condoms? That really does make a difference.

But also: this may be tricky in the US (it's FDA-approved, but not popular and some gynos don't even know about it), but if you can get your hands on a cervical cap, I LOOOOOOOVE mine. It's kind of like a more form-fitting diaphragm; it fits directly over the cervix (there are some women whose cervixes are a little more "flush" with the vaginal wall and are thus not able to use them), and uses spermicidal goop; but you can put it in once and leave it in for 24 hours straight, having sex as many times as you want in that period. Some people don't like diaphragms because if you wanted to have sex again you have to take it out and put more goop on and put it back in again; the cap lets you skip that part.

The only downside I experienced is that you have to wait at least 7 hours after having had sex before taking it out; and sometimes, that felt a little uncomfortable for me after hour 4. They can develop a bit of suction, which helps hold it in place during sex, but can feel a little crampy after a while (once I took it out, though, that totally went away; it never got more uncomfortable than mild menstrual cramps). Other times, I never felt it at all - which had its own drawback (I accidentally left it in for a week, and my gyno had to give me a couple days of antibiotics just in case so I didn't get toxic shock). But those are MINOR problems, I've found.posted by EmpressCallipygos at 7:22 AM on October 10, 2011

An IUD is designed to work for 5 years, but you can have it removed at any time! I would definitely suggest it.posted by Eicats at 7:23 AM on October 10, 2011 [4 favorites]

It's always a crap shoot with hormonal contraception, and it's really a discussion you can only have with your doctor. For instance, I cannot tolerate oestrogen (NuvaRing made me feel insane), but I get next to no side effects from progesterone and was on Implanon for 10 years, until I started to notice some hair loss (but, then again, I was on it for 10 years without a break).

I actually have an appointment to get an IUD (Paragard) inserted next week, and it's my understanding that it doesn't adversely affect your fertility afterwards. Likewise with other options, like Nuvaring and Implanon. I think these forms of birth control have a reputation for being long term because they can be long term, but when you choose to go off them your fertility returns.

But, again, this is a conversation between you and your doctor. Everyone's body is different, and women have horrible - and great - experiences with every form of birth control. If you rely on anecdata to make your decision you'll drive yourself crazy.posted by nerdfish at 7:23 AM on October 10, 2011

Rhythm method, spermicidal gel, and pulling out? They're not the most effective methods, but it seems like you wouldn't be completely dismayed by an accidental pregnancy?posted by whalebreath at 7:31 AM on October 10, 2011 [2 favorites]

The copper IUD (Paragard) has no hormones, so there's no worry about your body readjusting, and can be taken out whenever you want.

I've had mine for about a year and a half, and it's okay. It gets the job done, even though I have much, MUCH longer periods now.posted by roomthreeseventeen at 7:33 AM on October 10, 2011

In your position, I'd use the vaginal contraceptive films in conjunction with fertility awareness. I'm sure you've heard of Toni Wechsler's Taking Charge of Your Fertility, if not - it's fantastic. Even if it doesn't change how you deal with contraception, if you do decide to have a child it will be so useful to have all the information already at hand. And I apologize if you already know all that :) Good luck. I used the films for quite a while and they are cheap, convenient, and effective.posted by lemniskate at 7:49 AM on October 10, 2011 [3 favorites]

Does it need to be hormonal birth control? You could try using the Fertility Awareness Method (basically charting certain changes in your body every day). This is NOT the Rhythm Method, but it is similar to the Natural Family Planning Method.posted by pised at 7:50 AM on October 10, 2011 [1 favorite]

Nuvaring is just like the pill except monthly, it's very convenient. If you take it out and don't put it in the following week, then you'll start ovulating the next month (depending on how normal your cycle was to begin with).posted by echo0720 at 7:50 AM on October 10, 2011

I had an Implanon, and although they are supposed to work for three years I got mine taken out early because of irregular bleeding patterns. If you are one of the lucky ones who does not have this side effect, or it's not severe enough to be troublesome, hurrah! and if you do have problems they can remove them very quickly. I called my doctor, said the side effects sucked and they had me in the office within a week, and in two minutes the thing was out of my arm. Done. Easy peasy. Totally worth trying it out even though it didn't work out for me.posted by slow graffiti at 8:00 AM on October 10, 2011

And I forgot, MAJOR CAVEAT: Implanon has not been demonstrated to be clinically effective in people with your BMI, and I think they put a warning for that on their website. Talk this over with your gyno because that is true for Nuvaring and many other low dose modern OCs as well; the dose is so low that it may not be high enough to be effective in someone with greater body mass. It may be, they just haven't proven that it works and you would need to monitor yourself carefully to be sure you were not ovulating. I'm not saying this to suggest you need to lose weight or anything, it's just a problem with modern low dose birth control that was designed for someone who weighs about ~150posted by slow graffiti at 8:05 AM on October 10, 2011

FAM is totally an option for you, but (and I know this is obvious) the thing about FAM is that although it actually has really good stats when practiced perfectly by people with iron self-control, if it's going to fail, it's basically going to fail when you're ovulating, so there's very little wiggle room.

I think IUDs are great. My understanding is that your fertility returns really quickly, as well. The downside is the slight hassle of insertion and the more major hassle that for some people, their insurance doesn't cover them very well. And they're fairly expensive (but of course really cheap over the long haul.)posted by thehmsbeagle at 8:31 AM on October 10, 2011

I take Cerazette a progestogen-only pill. Its designed for "older" ladies, the overweight and smokers - basically women who can't take the combined pill. Cerazette is as effective as the combined pill and has the same 'window' (12 hours).posted by missmagenta at 8:38 AM on October 10, 2011 [1 favorite]

Another shout out for the copper IUD, it shouldn't affect your fertility beyond the time it takes to get an appointment to have it removed. However, you won't be able to dreamily toss it aside and start making a baby RIGHT THIS SECOND should the mood take you both. This may or may not be a good thing for your situation, possibly one to ponder in the pros and cons list.posted by freya_lamb at 9:21 AM on October 10, 2011

The IUD is meant for longer-term use, but it can be removed at any time. Anecdata: from the experiences of some people I know, the hormones must leave your body quicker than with oral contraceptives, because they've gotten pregnant pretty quickly after removal.

Seeing several suggestions about an IUD. A counterpoint -

My wife just got a non-hormonal IUD. She's heading for 40 and I'm just over it and certain issues are steering us towards adoption. So we weren't looking for a short-term solution. Since she was looking to address some hormonal difficulties the pill had been creating we went non-hormonal.

Used to be places were reluctant to do an IUD implantation for someone who hadn't had kids. Part of that is the permanence and risk of scarring, which seems to be less of a concern now. However one thing has not changed, which is that it's expected to be much more painful for someone who hasn't given birth.

In my wife's case it was extremely painful; as we were leaving the office where the implantation was done she commented that she was surprised I hadn't heard her cry out from where I was sitting in the waiting room. She experienced discomfort of varying degrees for almost two weeks.

From three months down the road it seems to both of us to have totally been worth it. However I imagine if you asked her that she would say she would not have gone through that for the sake of just a year or two.

You might have a better implantation than her; I'd say she does have a lower than average pain tolerance. However I'd strongly suggest you talk to some people you know and trust who have not gone through childbirth and who have chosen the IUD before you opt for it.posted by phearlez at 10:03 AM on October 10, 2011

Of course no one on this forum is offering medical advice, so I'm just going list some things to think about when you talking to you Doctor/Gynecologist about birth control.

What oral contraception did you use before? Most of the time doctors like to use pills that have worked well in the past, because each person's response to hormonal contraception is so individual or idiosyncratic, if something worked its hard to argue for changing it. Did the previous pills lead to weight gain? You said they worked well, why would you not return to using the same pill?

Progestin Only Pills aka Minipills (like Cerazette) are sometimes chosen because their side effects may be more tolerable for some women, and they are less likely to cause the major complications that your age and weight may put you at risk for. However, they can still cause weight gain in some patients. A new type of progestin called Drospirenone is supposed to cause less weight gain, but IANAGyn, so I am no expert.

Fertility awareness/natural family planning can be dependent on how regular your menses are. Even if you are using methods that try and 'detect' ovulation (which require quite a bit of commitment!) they are typically not recommended for people who have irregular periods. Older women nearing perimenopause and women with higher BMI's are at risk for having anovulatory cycles, basically cycles that become irregular and hard to predict, which may mean these methods aren't for you.

Cervical Caps are just one type of barrier method, along with diaphragms, and female condoms. They all have the same failure rate, which is roughly equivalent to the failure rate associated with Fertility awareness and "pulling out," i.e. it works when it is done perfectly but people rarely do it perfectly. My understanding of the diaphragms and caps is they have to be fitted, which takes time, and they may need to be refitted if your weight has gone up or down by 10 pounds. If your weight is still fluctuating significantly this may not be ideal for you.

Nuvaring is a new one so I don't know as much about it, but in general, the lower the dose of hormones, the less likely you will experience hormone related side effects (like weight gain or clotting). Hence people love Nuvaring and IUDs because since they release hormone directly to or nearby the area the hormone acts upon, the dosage is low and the side effects are more tolerable. Also, one commenter mentioned there may be less of a lag time between stopping therapy with Nuvaring and regaining fertility. This may be true, but while doctors will say there is typically 2-3 cycles between stopping hormonal birth control and returning to regular fertile cycles, it is also very possible to get pregnant two weeks after your last pill, each body is different. Also, IUDs work best for long term birth control, but that doesn't mean they have to be long term. It's a simple appointment with your GYN to get the IUD removed.

Lastly, what are you expectations of your future fertility? One thing I implore you to talk to your gynecologist about is setting up realistic time frame for starting a family. I don't want to rush you in a new relationship, but every GYN I've talked to mentions how recently many patients greatly over estimate the ability of women to conceive in their mid to late forties. I blame People magazine. Truth is, the average time between "trying to conceive" and actually producing a baby starts to increase in your early to mid 30s. When do the women of your family typically start menopause? How regular are your cycles? Any history of the women in your family having "surprise" late pregnancies? Are you open to seeing a fertility specialist? These are all things to think about.

Also, just so I don't worry about ya, both you and your boyfriend have been tested for HIV 3-6 months after ending things with your last partner, right? Cause even though you're definitely 'low risk' for STDs, those in public health rest easier when people use THAT as their definition of STD free.posted by midmarch snowman at 10:09 AM on October 10, 2011

My understanding of the diaphragms and caps is they have to be fitted, which takes time, and they may need to be refitted if your weight has gone up or down by 10 pounds.

I can offer an anecdotal dissent to this -- you do have to be fitted for the INITIAL purchase, but I hadn't heard anything about getting re-fitted for weight changes. In fact, I weight only 125 when I got mine, then went back to condoms for a while, and when I picked it up again I'd gained 40 pounds and when I went to get re-fitted my doctor found that there had been no change. As for the initial fitting, the time between getting fit for the first one and the time I got it took only a week.posted by EmpressCallipygos at 10:24 AM on October 10, 2011

(and to clarify -- the reason I went back to get refitted after a lapse in the first place was about "it's been over 10 years since I used this thing", and not about weight as such. A ten-year gap was long enough that I wanted to make sure everything would be copacetic, but 10-pound shifts in weight don't necessarily strike me as cause to schedule an appointment.

(Of course, if one's own doctor says otherwise, then their word trumps mine. My instance is anecdotal. Your mileage may vary. Contents may settle upon shipping. Refrigerate after opening. May contain nuts.)posted by EmpressCallipygos at 10:37 AM on October 10, 2011

Since other people have covered alternatives to the condoms.

My new boyfriend, though, whom I like very much, doesn't do well with condoms. (He's bigger than average. He doesn't get off with them very often. And they sometimes break.)

When I demo condoms, I make a fist, roll the condom down, continuing all the way past the wrist. Then spread fingers and thumb as wide as they go. The ruler says that's 7 inches. Then I insert my other hand into the condom and pull the hands apart until there's 1-2 inches of air between them, and spread all ten fingers those 7 inches wide again. Then I remove it, intact. I have long pointy fingernails, and the condoms are not magnums.

Condoms don't break because a penis is too big.

Here's how you break a (latex) condom: put any oil-based product on it, and wait a few minutes. Vaseline, crisco, olive oil, you name it.

Also good for breaking condoms: improper storage (avoid wallet!), or insufficient lubrication.

Before you give up on a BC method that's worked for you well up to now:
* ulra-thin condom (yes, really)
* put a drop or two of lube inside tip of condom
* copious amounts of lube for you
* replenish lube frequently if it's water-based
* no oils if the condom is latex
* a backup form of BC until you're confident

An IUD is designed to work for 5 years

12 year lifetime, if the IUD is Paragard. Mirena's hormone supply runs out some time after 5.posted by nakedcodemonkey at 9:30 PM on October 10, 2011

You are totally fine for an IUD. A friend of mine had hers removed and gave birth to her son 8.5 months later, full term -- as far as they can tell, she conceived her baby the day after the IUD was removed.

However. . . before you go doing any of this, see a doctor for a fertility workup. I wish it weren't so, but conception after 40 is just not that easy for many/most women. If that seems daunting, then go spend the $25 on one of those FSH tests they sell at the drug store and pee on it the third day after your period starts; those are quantitative not qualitative, but it should give you at least a rough idea of where your ovarian reserve is.posted by KathrynT at 12:18 AM on October 11, 2011

the nueva ring is month to month, no contracts.posted by jb at 9:45 AM on October 11, 2011 [1 favorite]

Personally, at your age I'd have the baby - even if the boyfriend doesn't suit in the long run, the baby definitely will. Not saying there aren't any around, but I've never met a 40 something woman who regretted having a first child, even with no partner around (and some of those women, with no partner, are in their 60's now, and still so happy that they got pregnant when they did).posted by nickji at 7:20 AM on October 14, 2011

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